Professor David Veale, Consultant Psychiatrist, The Priory … · transdiagnostic’ in that they were elevated in all disorders tested and in at least four different disorders. A

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Cognitive Therapy and Research ISSN 0147-5916 Cogn Ther ResDOI 10.1007/s10608-014-9641-9

The Cognitive Behavioural ProcessesQuestionnaire: A Preliminary Analysiswithin Student, Mixed Clinical andCommunity Samples and the Identificationof a Core Transdiagnostic ProcessTrishna Patel, Warren Mansell & DavidVeale

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ORIGINAL ARTICLE

The Cognitive Behavioural Processes Questionnaire:A Preliminary Analysis within Student, Mixed Clinicaland Community Samples and the Identification of a CoreTransdiagnostic Process

Trishna Patel • Warren Mansell • David Veale

� Springer Science+Business Media New York 2014

Abstract Theorists have highlighted the commonalities

in cognitive and behavioural processes across multiple

disorders i.e. transdiagnostic approach. We report two

studies that tested the psychometric properties of a new

scale to assess these processes. The Cognitive and

Behavioural Processes Questionnaire (CBP-Q) was devel-

oped as a 15-item measure. In Study 1, the CBP-Q was

administered to a student (n = 172) sample with a range of

standardised measures of the processes and symptom

measures. Study 2 repeated the evaluation in a mixed

clinical group (n = 161) and a community control group

(n = 57). An exploratory factor analysis resulted in a

12-item version of the CBP-Q, consisting of a single factor.

The measure demonstrated good internal consistency, test–

retest stability and satisfactory convergent and divergent

validity in both studies. Correlations with symptom-based

measures showed increased engagement in these cognitive

and behavioural processes to be associated with higher

levels of symptomatology. The scale was elevated in the

clinical relative to the community group and there were no

differences in scores between broad diagnostic groupings

(anxiety vs. mood vs. other). The CBP-Q has good psy-

chometric properties. The findings are consistent with the

transdiagnostic approach and indicate that a single, as yet

unspecified factor may account for the shared variance

across cognitive and behavioural maintenance processes.

Keywords Transdiagnostic � Cognitive processes �Behavioural processes � Control theory

Introduction

Increasingly, clinicians and researchers have begun to

recognise the commonalities in cognitive and behavioural

processes across different psychological disorders and their

role in the development and/or maintenance in a range of

symptoms, functioning and quality of life. Consequently,

several prominent groups of researchers and clinicians

have provided a range of benefits for moving towards a

transdiagnostic approach to cognitive behavioural therapy

(CBT; Craske 2012; Harvey et al. 2004; Hayes et al. 2013;

Mansell et al. 2009; McHugh et al. 2009; McManus et al.

2010). Yet, the empirical, theoretical and clinical status of

the transdiagnostic approach lags behind the ambitions of

its supporters. More specifically, few researchers have

attempted to develop a parsimonious account of the wide

variety of different transdiagnostic approaches that have

emerged, and in turn, to develop a clinically useful mea-

sure that encompasses them. The current study was

designed to begin such a scientific endeavour.

Earlier versions of the data were submitted as a Doctoral thesis at the

University of East London in 2010 for the Professional Doctorate in

Clinical Psychology and presented at the following conferences:

International Control Systems Group conference, Manchester, 2010;

North East London Foundation Trust Annual Research and

Development conference, London, 2011 and British Association for

Behavioural and Cognitive Psychotherapies Annual conference,

Guildford, 2011.

T. Patel (&)

School of Psychology, University of East London, Water Lane,

London E15 4LZ, UK

e-mail: [email protected]

W. Mansell

University of Manchester, Manchester, UK

D. Veale

South London and Maudsley NHS Foundation Trust, London,

UK

D. Veale

The Institute of Psychiatry, King’s College London, London, UK

123

Cogn Ther Res

DOI 10.1007/s10608-014-9641-9

Author's personal copy

The term ‘cognitive and behavioural processes’ will be

used in this article to refer to the psychological processes

across the domains of attention, memory/imagery, thinking,

reasoning and behaviour that have been found to maintain

distress in people with psychological disorders. In their key

systematic review, Harvey et al. (2004) analysed the large

number of published studies that examined these processes

in samples with diagnosed psychiatric disorders. They

identified that 12 of these were identified as ‘definitely

transdiagnostic’ in that they were elevated in all disorders

tested and in at least four different disorders. A further three

were identified as ‘possibly transdiagnostic’. Readers are

referred to Harvey et al. (2004) and Mansell et al. (2008) for a

complete list of these processes. Since then, a number of

studies have further supported the review and identified other

possible cognitive and behavioural processes as transdiag-

nostic, such a emotion-reactive impulsivity (Johnson et al.

2013) and intolerance of uncertainty (McEvoy and Mahoney

2012). Thus, there is a significant challenge to begin to assess

this wide range of processes and to understand their simi-

larities and differences from one another.

Importantly, there is increasing evidence that these cog-

nitive and behavioural processes are themselves highly

correlated. Several studies have discovered this through

conducting a factor analysis of multiple measures of cogni-

tive and behavioural processes and finding that a one-factor

solution explained the majority of variance among the scales.

An analogue study of 559 students revealed that a single

factor accounted for the majority of variance in intrusion

interpretation, rumination, worry, obsessive beliefs and

shame and this correlated more strongly with social anxiety

than the individual scales (Field and Cartwright-Hatton

2008). They termed this factor a ‘transprocess’ but could not

specify exactly what it measured. Similarly, a single factor

derived from experiential avoidance, worry and rumination,

correlated with distress in a chronic physical illness sample,

and predicted distress at three month follow-up in a student

sample (Bird et al. 2009). The extracted factor in this study

was termed ‘uncontrollable negative thinking’.

Two further relevant studies of analogue samples can be

identified from the literature. One study of 252 students

assessed four processes (rumination, thought suppression,

reappraisal and problem-solving) and found that both

rumination and thought suppression loaded on a single

process termed ‘cognitive emotion regulation’ This was

defined as a set of ‘‘cognitive responses to emotion-elicit-

ing events that consciously or unconsciously attempt to

modify the magnitude and/or type of individuals’ emo-

tional experience or the event itself’’. The single factor was

associated with symptoms of anxiety, depression and eat-

ing disorders in this cross-sectional sample (Aldao and

Nolen-Hoeksema 2010). A further cross-sectional study of

312 undergraduates found that a single factor of ‘emotion-

reactive impulsivity’ could be extracted from diverse

measures of impulsivity (Johnson et al. 2013). A regression

analysis revealed that this factor was associated with

transdiagnostic symptoms including aggression, anxiety,

borderline personality symptomology, and alcohol prob-

lems, and the factor was defined as ‘‘poor control over

impulsive reactions to emotions’’.

It is evident from the research reviewed above that there

is no consensus with regards to explaining the reason why

measures of cognitive and behavioural processes are clo-

sely correlated and what this overlap represents from a

theoretical perspective. Nevertheless, it holds promise that

a transdiagnostic form of CBT could target this factor,

which we shall term a ‘core process’. Furthermore, the

above studies have utilised a limited range of existing

standardised self-report measures within either analogue

samples, or a relatively circumscribed clinical sample. This

entails a limit to the range of potential processes that can be

assessed and the generalizability of the findings. Indeed,

there are no studies that have combined measures of mul-

tiple cognitive and behavioural processes in a single

questionnaire. Our novel approach was therefore to

develop a new questionnaire that samples the full range of

cognitive and behavioural processes identified by Harvey

et al. (2004), and that surveys a wide range of psycho-

logical disorders. This scale would not only benefit from

greater generalizability through its use of a wider range of

cognitive and behavioural processes, but also serve as a

clinical tool to use in transdiagnostic approaches to CBT.

We therefore developed a short, efficient, personalised,

self-report scale of a wide range of cognitive and behav-

ioural processes, within a consistent format that is anchored

within the individual’s current problem situations. The

scale is designed to be used to both refine disorder-based

CBT and to inform transdiagnostic CBT, which does not

require information about diagnosis to begin formulation

and treatment (Mansell et al. 2009). It is designed to easily

monitor the key cognitive and behavioural processes

known to maintain distress across psychological disorders,

so that they can be discussed, formulated, and targeted,

such as through behavioural experiments.

We conducted two studies to examine the scale’s psy-

chometric properties and tested specific hypotheses. First,

following on from earlier studies extracting a single factor

from a number of measures of cognitive and behavioural

processes, we predicted that the 15 cognitive and behav-

ioural processes assessed by the new scale would share

substantial variance, potentially leading to a single factor

solution. Second, consistent with the scale assessing

transdiagnostic processes that maintain distress, we pre-

dicted that scores on the scale would correlate with

symptoms of both anxiety and depression, and that they

would be elevated in clinical versus community samples.

Cogn Ther Res

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Finally, we predicted that, given the scale assesses the

features of cognitive and behavioural processes that are

shared across disorders, the total scores on the scale would

not be different between diagnostic groupings within a

clinical sample.

Study 1

Introduction

At an initial stage, it was important to provide a pre-

liminary test of the psychometric properties of the scale

prior to assessing clinical and community samples. A

sample of psychology students was therefore recruited

through a course credit scheme. This represented a rela-

tively homogenous sample in terms of age, social class,

experience and environment.

Method

Design

A cross-sectional study of students using self-report mea-

sures examined test–retest reliability, convergent validity

and factor analytic structure of a new questionnaire.

Participants

A total of 172 students were recruited: Five males and 167

females, M age (SD) = 19.50 (2.97). Their ethnic status

was as follows: 72.6 % White British, 6.4 % White Other,

0.6 % Black or Black British, 19.8 % Asian or British

Asian and 0.6 % Mixed background. We found that 6.4 %

of the sample reported a mental health diagnosis: 3 (1.7 %)

obsessive compulsive disorder, 1 (0.6 %) panic disorder, 6

(3.5 %) depression and 1 (0.6 %) borderline personality

disorder. There was a comorbidity rate of 1.2, 1.7 % taking

psychotropic medication and 1.7 % receiving psychologi-

cal therapy.

Materials

Cognitive and Behavioural Processes Questionnaire (CBP-

Q)

This scale was developed in a series of stages involving

feedback from researchers and piloting with ten clinical

and ten non-clinical participants who were not included in

the main analysis. The first stage of construction involved

reviewing the cognitive and behavioural processes identi-

fied as transdiagnostic (e.g. Harvey et al. 2004) in order

to assess which ones could be represented within a

questionnaire format. This was a challenge because many

earlier studies had largely used experimental paradigms to

assess some of the processes. For this reason, explicit

selective memory, and interpretative biases were omitted.

Metacognitive beliefs were also omitted because they

assessed beliefs about processes rather than capturing the

main aim of the questionnaire—to measure the processes

themselves.

The researchers adhered to key principles regarding

questionnaire construction in terms of wording and rating

scales (Barker et al. 2002). The questionnaire stated that

the questions referred to when participants ‘feel bad’ in the

past week in order to ground the responses in everyday

problematic situations that would be sensitive to change.

It was also a challenge to generate items that were brief,

reader friendly and able to encapsulate experiences across

multiple disorders, without referring to disorder-specific

concerns. To help structure items, attention shifted to lay-

out. As the focus of the questionnaire was on cognitive and

behavioural processes, it was decided that the scale should

be divided into these two domains. Once this decision had

been made, it became apparent that many of the processes

within the cognitive section could be collapsed further, thus

specific questions on thoughts, or recurrent memories for

example, would not be necessary. Consequently in part A

(cognitive section), it was decided not to differentiate

between thoughts, feelings, bodily sensations, voices,

urges, memories, or images, because they would be expe-

rienced across disorders in some form or another. They

were therefore termed ‘internal experiences’ and questions

were generated based on what individuals might do men-

tally in response to those experiences. These were: avoid-

ance/suppression, mental control, thought-action fusion,

rumination, worry and self-criticism. Part B referred to

various processes that interfaced with the environment

rather than internal experiences. They were: hypervigilance

for threat, safety-seeking behaviour, behavioural avoidance

(including inactivity and overactivity), and experiential

avoidance using alcohol, drugs, food or activities.

Each item utilised the semantic differential method

(Snider and Osgood 1969) to counter response acquies-

cence. It provided a verbal description of the two extremes

of a process, e.g. for hypervigilance, ‘‘How much have you

looked for possible harm or threats in your surroundings

when feeling bad, rather than just noticing things around

you?’’ This was followed by a 9-point (0–8) graphic Likert

scale that was used to assess the degree of self-reported

engagement with each process, e.g. 0 = Always looked for

threats; 2 = Mostly looked for threats; 4 = Equal;

6 = Mostly just noticed things around you; 8 = Always

just noticed things around you. Total scores range from 0 to

120. Table 1 reproduces the exact statements used in the

scale, but readers are invited to contact the authors to

Cogn Ther Res

123


obtain the appropriately formatted scale for further

research. This includes the full written instructions given to

participants around how to complete the scale, and how

‘internal experiences’ were defined.

White Bear Suppression Inventory (WBSI)

The WBSI (Wegner and Zanakos 1994) was developed to

assess the extent to which individuals suppress unwanted

negative thoughts. It is a 15-item self-report questionnaire,

adopting a 5-point scale ranging from 1 (strongly disagree)

to 5 (strongly agree). Scores range between 15 and 75, with

a higher score indicative of higher levels of suppression.

The WBSI has demonstrated good reliability (i.e. internal

consistency and test–retest stability) and validity (Muris

et al. 1996).

Acceptance and Action Questionnaire (AAQ)

This is a 9-item self-report scale, measuring experiential

avoidance, i.e. the avoidance of unwanted internal experi-

ences (Hayes et al. 2004). It consists of self-statements (e.g.

‘I’m not afraid of my feelings’), which are rated on a scale

of 1 (never true) to 7 (always true). Items 1, 4, 5 and 6 are

inversely scored. A higher score is indicative of higher

experiential avoidance, scores range from 9 to 63. The AAQ

has demonstrated moderate reliability in terms of internal

consistency and good discriminant validity (Baracca Mairal

2004; Boelen and Reijntjes 2008; Hayes et al. 2004). It has

adequate criterion-related, predictive and convergent

validities (Bond and Bunce 2003; Hayes et al. 2004).

Cognitive Attentional Syndrome (CAS-1)

This is a 16-item self-report measure of cognitive processes

and meta-cognitive beliefs held by individuals diagnosed

with a range of anxiety disorders and depression (Wells

2009). Responses to questions 1–3 are restricted to the past

week and rated on a scale of 0 (none of the time) to 8 (all of

the time). Question 1 assesses worry and rumination, pro-

ducing a single score. Question 2 evaluates threat moni-

toring. Question 3 looks at unhelpful self-regulatory

behaviours; the 6-items within this question are summed to

produce a score between 0 and 48. Question 4 looks at

meta-cognitive beliefs held by individuals: negative and

positive beliefs. The items are rated from 0 (I do not

believe this at all) to 100 (I’m completely convinced this is

true). The 4-items within each column are summed to

produce two scores, one for negative meta-cognitive beliefs

and one for positive meta-cognitive beliefs.

Penn State Worry Questionnaire (PSWQ)

The PSWQ (Meyer et al. 1990) is a 16-item self-report

questionnaire measuring worry across time and contexts, as

well as the intensity and perceived uncontrollability of

worry. Items are scored on a 5-point Likert scale, from 1

(not at all) to 5 (very). Items 1, 3, 8, 10 and 11 are inversely

Table 1 Factor loadings of CBP-Q items for student and clinical

samples

Item Student Clinical

Part A

1: How much have you focused on your internal

experiences when feeling bad, rather than focusing

on what is happening in your surroundings

0.19 0.38

2: How much have you tried to mentally avoid or get

rid of unpleasant internal experiences, rather than

just noticing them and letting them pass

0.04 -0.07

3: How much have you tried to change or mentally

control your internal experiences when feeling bad,

rather than just noticing them and letting them pass

-0.13 0.01

4: How much have you gone over and over past

experiences when feeling bad, rather than doing the

things that are important to you

0.44 0.46

5: How much have you worried about bad things that

might happen in the future, rather than doing the


0.43 0.52

6: How much have you judged yourself or your

appearance to other people when feeling bad, rather

than just noticing people around you

0.62 0.49

7: How much have you let your internal experiences

rather than what you see and hear in the moment,

guide what you do

0.40 0.52

8: How much have you analysed past events for

answers when feeling bad, rather than doing the


0.45 0.50

Part B

9: How much have you looked for possible harm or

threats in your surroundings when feeling bad,

rather than just noticing things around you

0.59 0.70

10: How much have you looked for things in your

surroundings to make you feel safe when feeling

bad, rather than just noticing things around you

0.40 0.64

11: How much have you avoided dealing with an

actual problem when feeling bad, rather than doing

something to solve the problem

0.79 0.48

12: How much have you distracted yourself from

feeling bad by doing an activity too often, rather

than doing the things that are important to you

0.77 0.69

13: How much have you been inactive or avoided

situations, activities or people when feeling bad

rather than doing the things that are important to

you

0.70 0.61

14: How much have you done something negative to

stop yourself feeling bad, rather than just

experienced feeling bad

0.70 0.71

15: How much have you used alcohol, drugs, food or

an activity to reduce or prevent unpleasant internal

experiences, rather than just ‘‘be with them’’?

0.80 0.70

Eigenvalue 6.2 5.8

% of variance 42 38

Loadings [ .40 are displayed in bold

Values are italicized to differentiate them from the factor loadings

Cogn Ther Res

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scored. Scores range between 16 and 80, with a higher

score indicating high levels of worry. The PSWQ has

demonstrated good test–retest reliability, internal consis-

tency and high validity (Meyer et al. 1990; Molina and

Borkovec 1994).

Patient Health Questionnaire (PHQ-9)

The PHQ-9 is a brief self-report measure of depression

restricted to experiences over the last 2 weeks (Kroenke

et al. 2001). Items are rated from 0 (not at all) to 3 (nearly

every day), with scores ranging from 0 to 27. Kroenke and

Spitzer (2002) stated the following cut-off points have been

assigned to denote different levels of depression: 5–9

(mild), 10–14 (moderate), 15–19 (moderately severe) and

20–27 (severe). The PHQ-9 has demonstrated good validity

properties: construct and criterion validity (Kroenke et al.

2001). Internal consistency of the measure has been shown

to be high (Cameron et al. 2008; Lee et al. 2007).

Generalised Anxiety Disorder Questionnaire (GAD-7)

The GAD-7 was developed as a self-report measure of

generalised anxiety (Spitzer et al. 2006). The 7-items are

confined to experiences over the last two weeks and rated

on a scale from 0 (not at all) to 3 (nearly every day). Scores

range from 0 to 21, with a higher score suggestive of higher

levels of anxiety (5–9: mild, 10–14: moderate, 15–21:

severe). The measure has demonstrated good reliability and

criterion, construct, factorial and procedural validity

(Spitzer et al. 2006). Good reliability and validity proper-

ties have not only been shown in primary care settings but

in the general population as well (Lowe et al. 2008).

Procedure

The study received university ethics approval. All partici-

pants read an information sheet and completed a consent

form. They then completed the questionnaires, in the order

presented within the Material section, either in paper form

or electronically online via a URL created through Select

Survey. To assess the test–retest reliability of the CBP-Q,

the questionnaire was re-administered a week later to 52

participants who agreed to be re-contacted.

Analyses

The z-scores of skewness and kurtosis were utilised,

Shapiro–Wilk tests were conducted and histograms visu-

ally examined, confirming the total CBP-Q scores were

normally distributed. Internal consistency was examined

using Cronbach’s alpha. Pearson’s correlation was used to

examine test–retest reliability.

An exploratory factor analysis was conducted using

FACTOR version 9.2 (Lorenzo-Seva and Ferrando 2013),

to investigate the factor structure of the CBP-Q. Optimal

implementation of Parallel Analysis (PA) (Timmerman and

Lorenzo-Seva 2011) was used. This method was chosen as

it is more accurate than other methods in determining the

number of components/factors to extract during factor

analysis (Timmerman and Lorenzo-Seva 2011; Wilson and

Cooper 2008; Zwick and Velicer 1986). Factors were

extracted using a principal components extraction method,

with this being followed by oblique rotation (direct obli-

min), permitting correlation between the emergent factors.

This was chosen because previous research, reviewed in

the Introduction, had indicated that the constructs to be

assessed in the scale were likely to overlap. We used the

questionnaire items that were associated (r [ .4) with the

extracted factor structure within further analyses.

Convergent validity was evaluated using Pearson’s

correlation between the total CBP-Q score (adjusted to

include only the reliable items) and both the process and

symptom measures.

Results

Reliability

Internal consistency was high (a = .90) and no item signifi-

cantly reduced the scale’s overall reliability. Test–retest reli-

ability was high (r = .74, p \ .001): baseline, M = 59.92

(SD = 17.94) and follow-up, M = 54.25 (SD = 18.27).

Factor Structure

There was no missing data within the student sample, with all

participants being included in the analysis, N = 172. Opti-

mal implementation of PA (Timmerman and Lorenzo-Seva

2011) was used to examine the factor structure of the CBP-Q.

This was computed using FACTOR version 9.2 (Lorenzo-

Seva and Ferrando 2013). Scores were normally distributed

and as a result Pearson correlation matrix was computed. A

principal components extraction method was employed,

using direct oblimin rotation. The Bartlett’s test of sphericity

(v2 = 1,049.0, df = 105, p \ .001) demonstrated that the

correlations between items were sufficiently substantial and

the Kaiser–Meyer–Olkin statistic (KMO = .90) suggested

the sample size was adequate for the analysis. One principal

factor was extracted, accounting for 42 % of the variance.

The factor loadings after rotation are reported in Table 1,

with all items apart from item 10 demonstrating adequate

communality. Items 4 to 15 correlated r [ .4 with the single

factor and were retained for a 12-item version. Notably, when

the analysis was repeated with a forced single factor solution,

all items loaded at r [ .4.

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Validity

Table 3 shows the correlations between the 12-item CBP-Q

and the various process and symptom measures. Conver-

gent validity was demonstrated with significant moderate

to strong correlations between the CBP-Q and all process

measures. As predicted, the scale correlated with both

anxiety and depression.

Discussion

Study 1 established good internal consistency, test–retest

reliability and construct validity for the scale. As expected

the scale correlated with symptoms of both anxiety and

depression. The extraction of a single factor also suggested

support for the core process account (Bird et al. 2009; Field

and Cartwright-Hatton 2008). The finding of a weak corre-

lation with positive metacognitive beliefs is somewhat

unexpected as these are related to other cognitive and

behavioural processes such as worry and compulsions as

assessed by the Metacognitions Questionnaire (MCQ)

(Cartwright-Hatton and Wells 1997; Wells and Papageorgiou

1998). It is possible that the CAS-1 assesses these beliefs

differently. Overall, these promising findings required rep-

lication in a clinical sample. Furthermore, owing to the idi-

osyncratic nature of a student sample, a further control

group—centred in the community—would provide a suitable

comparison group to further evaluate the scale for its capacity

to discriminate clinical from non-clinical samples.

Study 2

Introduction

Study 2 attempted to replicate the psychometric properties of

the CBP-Q in a clinical sample. In addition it also allowed the

remaining hypotheses to be tested: to compare the CBP-Q

across diagnostic groups, and through inclusion of a commu-

nity sample, allowed a comparison between clinical and non-

clinical groups on the questionnaires. The community sample

was recruited via a database of non-clinical participants willing

to take part in psychological research. This provided data from

people differing in a range of variables, and hence, more rep-

resentative of the general population. It allowed a more

appropriate comparison group for the clinical sample.

Method

Design

The internal consistency and construct validity of the scale

were examined in two separate cross-sectional samples—

clinical and community. The factor analytic structure of the

scale was assessed in the (larger) clinical sample. In

addition, group comparisons were made between the clin-

ical and community groups, and between the broad diag-

nostic groupings within the clinical sample.

Participants

A heterogenous treatment-seeking clinical sample was

recruited via adverts, service user organisations and clini-

cians, from a range of primary and secondary care in-

patient and outpatient services. They were required to have

received a mental health diagnosis and to report as cur-

rently symptomatic. The 161 individuals in the clinical

sample constituted 49 males, 102 females and 10 unknown

with a Mage (SD) of 39.9 (13.1). Their ethnic status was as

follows: 88.8 % White British, 5 % White Other, 1.9 %

Black or Black British, 1.9 % Asian or British Asian,

1.2 % Mixed background and 0.6 % unknown. A sizeable

proportion (36.8 %) reported comorbid diagnoses and the

reported number of years diagnosed with the ‘primary’

disorder ranged from one to over 10 years, with 38.5 %

participants experiencing these difficulties for more than

10 years. We found that 55.3 % participants were on

psychotropic medication and 71.4 % were receiving psy-

chological therapy. The vast majority of participants

reported mood (40.9 %) and anxiety (47.1 %) disorders,

with a minority reporting eating disorders (4.9 %), psy-

chosis (2.4 %) or somatoform disorders (1.2 %). Four

(2.5 %) participants did not specify their diagnosis. A full

breakdown of different diagnoses, including the number

with each diagnosis who have a comorbid condition is

presented in Table 2.

The community sample constituted 57 individuals: 13

males and 44 females, Mage (SD) = 33.18 (11.25). Their

ethnic status was as follows: 63.1 % White British, 12.3 %

White Other, 8.8 % Black or Black British, 10.5 % Asian

or British Asian and 5.3 % Mixed background. A sizeable

proportion (19.3 %) of the sample reported a mental health

diagnosis: 1 (1.8 %) post-traumatic stress disorder, 2

(3.5 %) social anxiety disorder, 7 (12.3 %) depression and

1 (1.8 %) borderline personality disorder. There was a

comorbidity rate of 3.5, 8.8 % taking psychotropic medi-

cation and 3.5 % receiving psychological therapy.

Procedure

The study received NHS ethical approval in addition to R&D

approval within the necessary trusts. The procedure was the

same as Study 1. Patients were given 24 hours to read the

information sheet before consenting to the study. They

completed the questionnaires either in their own time and

returned them to their clinician or to the service involved in

Cogn Ther Res

123


their recruitment or they completed them electronically

online via a URL created through Select Survey.

Analyses

The majority of analyses were the same as Study 1. In

addition, an independent samples t-test compared scores

between the clinical and community samples. A one-way

analysis of variance (ANOVA) was performed to compare

the CBP-Q scores between diagnostic groups, followed up

by Tukey HSD post hoc tests.

Results

Reliability

Internal consistency of the 15-item questionnaire was high

at a = .92 in both groups. Within each group, no item

significantly reduced the scale’s overall reliability.

Factor Structure in the Clinical Sample

Seven participants had missing data and were thus removed

from this analysis, as a result N = 154. Scores from the CBP-

Q were not normally distributed, with analysis of Mardia’s

multivariate asymmetry demonstrating a significant kurtosis

(coefficient 286.41, statistic 8.63, p \ .001). Consequently,

the Polychoric correlation matrix was computed. A principal

components extraction method was employed on the 15

items, with direct oblimin rotation. Bartlett’s test of sphe-

ricity (v2 = 1,125.9, df = 105, p \ .001) suggested that

correlations between items were sufficiently large for the

analysis to be run. The Kaiser–Meyer–Olkin test verified the

sampling adequacy for the analysis, KMO = .92. One prin-

cipal factor was extracted, accounting for 38 % of the vari-

ance. The factor loadings after rotation are reported in

Table 2. The same 12 items as Study 1 had a factor loading of

[.4. Notably, when the analysis was repeated with a forced

single factor solution, all items loaded at r [ .4.

Validity

The correlations between the 12-item version and both

symptom and process measures are displayed in Table 3.

They reflect many of the same patterns of moderate to

strong correlations as Study 1, and they confirmed the

hypothesised association between the scale and both anx-

iety and depression. However, the strength of correlation

with process measures was weak for negative meta-cog-

nitive beliefs and not significant for positive meta-cogni-

tive beliefs in the clinical sample.

Group Comparisons

As predicted, an independent samples t-test showed that the

mean score for the clinical group (M = 53.7, SD = 19.3,

SE = 1.5) was significantly higher than the community

sample (M = 43.5, SD = 18.2, SE = 2.4), t(214) = 3.5,

p B .001.

To test the third hypothesis that there would be no dif-

ference in scores between diagnostic groups, a one-way

ANOVA was conducted. Due to small sample sizes, par-

ticipants with a diagnosis other than an anxiety or mood

disorder were placed into a ‘mixed other’ category. The

mean scores between three diagnostic categories were

compared: anxiety (n = 75), mood (n = 65) and ‘mixed

other’ (n = 15). As predicted, there was no effect of

diagnosis on the CBP-Q score [F(2, 152) = 1.34, p = .26].

An exploratory analysis of group differences on individual

scale items using independent samples t-tests was also

conducted. Yet, even when not correcting for multiple

comparisons, no individual item on the CBP-Q differenti-

ated any of the three groups from one another, p [ .05.

Discussion

Study 2 largely replicated the findings of Study 1 in a

heterogenous treatment-seeking sample. The weak

Table 2 Numbers and percentages of individuals in the clinical

group with each diagnosis, including the number of comorbid cases

for each diagnosis

Diagnostic category N % Comorbidity (N)

Anxiety disorders

Agoraphobia 1 0.6 1

Generalised-anxiety 3 1.9 0

Obsessive–compulsive 11 6.8 5

Panic 2 1.2 1

Post-traumatic stress 4 2.5 3

Anxiety (unspecified) 55 34.1 12

Mood disorders

Bipolar (type 1 and 2) 25 15.5 3

Depression 40 24.8 15

Seasonal affective 1 0.6 0

Eating disorders

Anorexia 4 2.5 3

Bulimia 2 1.2 0

Eating disorder NOS 3 1.9 1

Schizophrenia and other psychotic disorders

Delusional 1 0.6 0

Paranoid 1 0.6 1

Schizoaffective 1 0.6 0

Schizophrenia 1 0.6 1

Somatoform disorders

Body dysmorphic 2 1.2 0

Cogn Ther Res

123


correlations between the CBP-Q, and the measures of

negative and positive metacognitive beliefs within the

clinical sample was unexpected, and the reasons were

unclear. Nevertheless, the study identified the predicted

group differences on the CBP-Q between clinical and non-

clinical samples, and provided some indication that the

scores on the scale as a whole did not differentiate diag-

nostic groupings, fitting with predictions of the transdiag-

nostic approach. Nevertheless, this does not preclude the

possibility the specific cognitive and behavioural pro-

cesses, included in the scale as individual items, might be

more evident in some disorders than others, despite being

‘transdiagnostic’ in the sense that people with any disorder

still report the process at higher rates than a non-clinical

sample (Harvey et al. 2004). For example, one study with a

diverse sample of patients found that different levels of

private self-consciousness differentiated social phobia as

having higher levels than panic disorder, which in turn

were higher than bulimia (Jostes et al. 1999). Yet, when we

attempted such an analysis on individual items, no evi-

dence was found for differences between the broad diag-

nostic groupings we had identified.

General Discussion

The CBP-Q was designed to fit with the transdiagnostic

approach to CBT. The principal objective of the research

was to undertake preliminary development and analysis of

the psychometric properties of the CBP-Q, in both a

clinical and control group. Specific hypotheses were that

the scale would correlate with symptoms of both anxiety

and depression, differentiate the clinical from the non-

clinical group, and not differentiate between diagnostic

groupings.

The initial 15-item CBP-Q had good internal consis-

tency and test–retest stability. The exploratory factor ana-

lysis revealed that most of the variance was explained by a

single factor, with items from Part A and Part B not being

distinguished by the factor analysis. The same factor

structure was extracted within both groups, with 12 items

loading highly onto the principal factor. One possible

reason for the first three items failing to correlate with the

extracted factor is that they were more abstract (e.g.

focused on/avoided/controlled internal experiences), in

contrast to the more concrete examples of other items (e.g.

analysed past events, look for potential harm). It is possible

that as the questionnaire progressed, participants developed

a clear personal idea of what the questions were referring

to. Considering also that the first three items did not cluster

together, it is likely that they do not represent a concep-

tually distinct subcategory of cognitive and behavioural

processes. Further evidence to support this view comes

from the finding that a forced single factor solution led to

all 15 items loading highly with the single factor in both

student and clinical samples.

Across studies, the CBP-Q converged appropriately with

measures assessing similar processes: AAQ, PSWQ and

subscales from the CAS-1: worry/rumination, threat mon-

itoring and unhelpful self-regulatory behaviours. Divergent

validity was evident in the weaker correlations between the

CBP-Q and subscales on the CAS-1 measuring meta-cog-

nitive beliefs, a construct not assessed by the CBP-Q.

The CBP-Q correlated strongly with measures of both

anxiety and depression within each sample, as would be

expected if it assesses processes that maintain psycholog-

ical distress. Similarly as expected, group comparisons

showed that the clinical group had a significantly higher

mean CBP-Q score than the community group. Analysis of

the CBP-Q scores across diagnoses was more difficult than

anticipated, due to low numbers of participants within

diagnostic categories other than anxiety and mood disor-

ders. Nevertheless, comparison categories of anxiety dis-

orders, mood disorders and ‘mixed other’ disorders,

revealed no effect of diagnostic category, which supports

the hypothesis that the processes measured by the CBP-Q

are not disorder specific. However, these findings need to

be interpreted with caution, as to allow sufficient numbers

for comparison many diagnoses were grouped together to

form a ‘mixed other’ category.

Encouragingly, findings from the current study support

the feasibility of a transdiagnostic approach to CBT.

Notably, items that appeared diverse on the surface—

Table 3 Correlations (Pearson’s r) between the CBP-Q (12 item

score) and standardised measures

Measures Study

1

Study 2

Student Clinical Community

White Bear Suppression Inventory .66** .52** .79**

Acceptance and Action

Questionnaire

.70** .62** .74**

Penn State Worry Questionnaire .60** .66** .71**

CAS-1: worry/rumination .56** .68** .73**

CAS-1: threat monitoring .56** .68** .72**

CAS-1: unhelpful self-regulatory

behaviours

.56** .53** .67**

CAS-1: negative meta-cognitive

beliefs

.41** .18* .50**

CAS-1: positive meta-cognitive

beliefs

.21** .02 .29*

Generalised Anxiety Disorder

Questionnaire

.56** .70** .72**

Patient Health Questionnaire .58** .67** .69**

CAS-1 Cognitive Attentional Syndrome

* p \ .05; ** p \ .001

Cogn Ther Res

123


measuring negative recurrent thinking, emotional reason-

ing, selective attention towards concern-related external

stimuli, attention to sources of safety, avoidance behaviour

and safety-seeking behaviour/experiential avoidance—all

loaded highly onto one factor. The identification of one

principal factor, a potential ‘core process’, provides pre-

liminary support for adopting a transdiagnostic approach.

The finding of one principal factor also provides empirical

support to the hypothesis of a core process model as pro-

posed by Field and Cartwright-Hatton (2008). This model

assumes that the numerous cognitive and behavioural

maintenance processes identified and studied in the litera-

ture can be represented by a single factor(s). This implies

that efforts should now be directed at investigating core

underlying processes that contribute to the development

and/or maintenance of psychological distress. However, it

is important to note that the principal factor explained less

than 42 % of the total variance, suggesting that there are

probably other important core processes that need to be

identified.

Labelling of the theoretical construct identified in the

current study remains tentative. Nevertheless, a variety of

theoretical explanations may explain the core process that

has been identified, including repetitive negative thinking

(Ehring and Watkins 2008), self-attacking (Gilbert 2005),

experiential avoidance (Hayes et al. 1999; Hayes et al.

2004) and meta-cognitive beliefs (Wells 2009). Yet a key

challenge for any of these accounts is the diversity of the

12 processes identified as closely related. An explanation

that evokes a higher order, abstract, construct may there-

fore be more suitable. Perceptual control theory (PCT;

Powers 1973) is a psychological framework that has

recently informed developments in transdiagnostic CBT

(Higginson et al. 2011; Mansell 2005; Mansell et al. 2012).

These accounts have proposed that the wide range of

maintenance processes identified are all examples of what

is termed ‘arbitrary control’. Any process that is carried out

without regard to the important personal goals that a person

holds has the potential to conflict with them. Thus, it is the

extent to which processes such as self-attacking, risk

seeking, avoidance, worry and rumination are utilised

without regard to the impact there are having on important

personal goals (e.g. to feel worthwhile; to achieve success;

to be close to other people) that is problematic. It is likely,

that the more frequent, pervasive and enduring these cog-

nitive and behavioural processes are engaged, the greater

goal conflict they cause. In turn, therapy based on PCT

involves questions directed at shifting and sustaining

awareness on problematic goal conflict to help patients

resolve the conflict and regain overall control of their lives

(Carey 2006; Mansell et al. 2012). It remains to be tested

whether the core process identified in this study can be

regarded as arbitrary control.

The studies were both relatively preliminary and had

several limitations. Most importantly there were key

decisions made about the design of the questionnaire and

the nature of the samples that could be challenged.

First, a self-report scale eliciting process-based infor-

mation needs to be interpreted with caution, as researchers

have suggested that individuals may not always be con-

sciously aware or able to monitor these cognitive or

behavioural processes, leading to potential problems with

validity (Gibbs and Rude 2004; Wells and Matthews 1994).

Some argue that individuals may be better at self-reporting

information related to thought content rather than thought

process (Ehring and Watkins 2008). However two other

process scales, the Appearance Anxiety Inventory (Veale

et al. 2014) and the Specific Phobia of Vomiting Inventory

(Veale et al. 2013) were able to identify two distinct factors

labelled threat monitoring and avoidance of threat. This

may be because the content of the items were relevant to

the individual with Body Dysmoprhic Disorder or a spe-

cific phobia of vomiting respectively.

Second, one of the difficulties of using the semantic

differential technique was that participants were forced into

choosing a response along a spectrum of contrasting

positions that they may not experience. For example the

question ‘how much have you focused on your internal

experiences when feeling bad, rather than focusing on what

is happening in your surroundings’ implies that these are

the only two responses that a person may experience.

Future versions of the questionnaire could insert a ‘do not

apply’ option or adopt the use of a unipolar scale, which

would involve measuring one construct that differs in

degree (Barker et al. 2002). In this case, it would involve

singularly measuring each aspect of the different con-

structs. However, this would result in a lengthy scale.

Regarding establishing diagnoses, these were either

reliant on self-report or obtained from the participant’s

clinician. The design of the study could have been

improved by using a diagnostic tool such as the SCID I

(First et al. 1995), which is most commonly used in clinical

research studies. However, due to restrictions on time, the

study was designed to increase the likelihood of partici-

pation, which meant that the use of the SCID I was not

feasible (e.g. online participation).

Sample size may have also been an issue. Despite the

sample size of the clinical and student groups being well

over a minimum of 75, ideally a good sample size for a

PCA would constitute approximately 300 participants

(Comrey and Lee 1992; Tabachnick and Fidell 2007).

Nevertheless, other researchers argue that a factor that has

more than four loadings greater than .6 can be considered a

reliable factor solution regardless of the size of the sample

(Guadagnoli and Velicer 1988). Positively, both the clini-

cal and student sample had more than four loadings greater

Cogn Ther Res

123


than .6. Notably, we could not conduct a factor analysis in

the community sample owing to its small size (n = 57).

This is a clear limitation, limits generalisability and is a

target for future research. The student sample was also

biased in terms of its preponderance of female participants.

Nevertheless, the factor structure was replicated in a clin-

ical sample with a 2:1 ratio of female to male participants,

which is more representative of the ratio within mental

health services.

Future studies could assess the validity of the CBP-Q by

means of larger sample sizes, with stricter diagnosis criteria

(e.g. SCID) and across a range of diagnostic groups to estab-

lish whether the processes measured are truly transdiagnostic

or specific to particular diagnostic categories. Individual items

from the questionnaire could be analysed against symptom-

based scales, to assess whether specific items are stronger than

others at predicting increases in symptomatology. In future

versions of the CBP-Q, it would be useful to generate addi-

tional items for processes that were not fully covered in the

current scale (e.g. a wider range of safety-seeking behaviours)

and for further thought to be given to the type of scaling

method that would be most appropriate for this kind of

questionnaire. Finally, the order of the different measures in

the study could be randomised or counterbalanced to reduce

any potential after effects of completing each scale.

Clinically the CBP-Q would be a useful tool to assess the

processes that need to be addressed during therapy. It could

be argued that the CBP-Q may potentially be clinically

more useful in providing information about the individual

needs of clients than diagnostic labels. Within transdiag-

nostic CBT, basic theory is used to build a formulation and

guide intervention without the need for a diagnostic

assessment, thereby making therapy more efficient and

reducing unnecessary delays as individuals are allocated to

different services, or individuals trained in different models,

based on their diagnosis (Mansell et al., 2009). Following

further research and validation, it has the potential of being

a useful tool to monitor progress during therapy and as an

outcome measure. More specifically, we expect that the

specific items (e.g. hypervigilance, worry) that are elevated

in an individual client can be discussed early on in therapy,

to inform the formulation and guide behavioural experi-

ments, thereby making therapy more efficient.

In conclusion, the findings from the study lend support

to the growing literature of studying cognitive and behav-

ioural processes across psychological disorders versus

disorder-specific phenomena (e.g. content and process).

The study demonstrated the CBP-Q to be a reliable self-

report scale, measuring one construct, hypothesised here as

attempts of arbitrary control. Convergent and divergent

validity were satisfactory.

However, systematic research studies will be required to

replicate and extend the findings from the current study,

with particular focus on the theory best able to account for

the identified core process.

Acknowledgments This study presents independent research part-

funded by the National Institute for Health Research (NIHR) Bio-

medical Research Centre at South London and Maudsley NHS

Foundation Trust and King’s College London. We would like to

acknowledge support from the Institute of Psychiatry, King’s College

London, which allowed volunteers from the community to be given

the option of receiving a £10 high street voucher. The views

expressed are those of the author(s) and not necessarily those of the

NHS, the NIHR or the Department of Health. We would like to thank

Matthew Jones Chesters (UEL) for his statistical advice, as well as

Lucy Serpell (UCL), and Six Degrees Social Enterprise for their help

with recruitment.

Conflict of Interest Trishna Patel, Warren Mansell and David

Veale declare that they have no conflict of interest.

Informed Consent All procedures followed were in accordance

with the ethical standards of the responsible committee on human

experimentation (national and institutional). Informed consent was

obtained from all individual subjects participating in the study. If any

identifying information is contained in the paper the following

statement is also necessary—Additional informed consent was

obtained from any subjects for whom identifying information appears

in this paper.

Animal Rights No animal studies were carried out by the authors

for this article.

References

Aldao, A., & Nolen-Hoeksema, S. (2010). Specificity of cognitive

emotion regulation strategies: A transdiagnostic examination.

Behaviour Research and Therapy, 48, 974–983.

Baracca Mairal, J. (2004). Spanish adaptation of the acceptance and

action questionnaire. International Journal of Psychology and

Psychological Therapy, 4, 505–515.

Barker, C., Pistrang, N., & Elliott, R. (2002). Research methods in

clinical psychology: An introduction for students and practitio-

ners (2nd ed.). Chichester: Wiley.

Bird, T., Mansell, W., & Tai, S. J. (2009). Method of levels: Initial

steps in assessing adherence and the development of a qualitative

framework for mapping clients’ control hierarchies. The Cogni-

tive Behaviour Therapist, 2, 145–166.

Boelen, P. A., & Reijntjes, A. (2008). Measuring experiential

avoidance: Reliability and validity of the Dutch 9-item AAQ.

Journal of Psychopathology and Behavioral Assessment, 30,

241–251.

Bond, F. W., & Bunce, D. (2003). The role of acceptance and job

control in mental health, job satisfaction, and work performance.

Journal of Applied Psychology, 88, 1057–1067.

Cameron, I. M., Crawford, R. J., Lawton, K., & Reid, I. C. (2008).

Psychometric comparison of PHQ-9 and HADS for measuring

depression severity in primary care. British Journal of General

Practice, 58, 32–36.

Carey, T. A. (2006). The methods of levels: How to do psychotherapy

without getting in the way. Hayward: Living Control Systems.

Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and

intrusions: The metacognitions questionnaire and its correlates.

Journal of Anxiety Disorders, 11, 279–296.

Comrey, A. L., & Lee, H. B. (1992). A first course in factor analysis

(2nd ed.). Hillsdale: Erlbaum.

Cogn Ther Res

123


Craske, M. G. (2012). Transdiagnostic treatment for anxiety and

depression. Depression and Anxiety, 29, 749–753.

Ehring, T., & Watkins, E. (2008). Repetitive negative thinking as a

transdiagnostic process. International Journal of Cognitive

Therapy, 1, 192–205.

Field, A. P., & Cartwright-Hatton, S. (2008). Shared and unique

cognitive factors in social anxiety. International Journal of

Cognitive Therapy, 1, 206–222.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W.

(1995). Structured clinical interview for DSM-IV axis I

disorders-patient edition (SCID-I/P, Version 2.0). New York:

Biometrics Research Department of the New York State

Psychiatric Institute.

Gibbs, B. R., & Rude, S. (2004). Overgeneral autobiographical

memory as depression vulnerability. Cognitive Therapy and

Research, 28, 511–526.

Gilbert, P. (2005). Compassion: Conceptualisation, research and use

in psychotherapy. Hove: Routledge.

Guadagnoli, E., & Velicer, W. F. (1988). Relation of sample size to

the stability of component patterns. Psychological Bulletin, 103,

265–275.

Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004).

Cognitive behavioural processes across psychological disorders.

Oxford: Oxford University Press.

Hayes, S. C., Long, D. M., Levin, M. E., & Follette, W. C. (2013).

Treatment development: Can we find a better way? Clinical

Psychology Review, 33, 870–882.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance

and commitment therapy: An experiential approach to behaviour

change. New York: Guildford Press.

Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J.,

Toarmino, D., et al. (2004). Measuring experiential avoidance: A

preliminary test of a working model. The Psychological Record,

54, 553–578.

Higginson, S., Mansell, W., & Wood, A. M. (2011). An integrative

mechanistic account of psychological distress, therapeutic

change and recovery: The perceptual control theory approach.

Clinical Psychology Review, 31, 249–259.

Johnson, S. L., Carver, C. S., & Joormann, J. (2013). Impulsive

responses to emotion as a transdiagnostic vulnerability to

internalizing and externalizing symptoms. Journal of Affective

Disorders, 150, 872–878.

Jostes, A., Pook, M., & Florin, I. (1999). Public and private self-

consciousness as specific psychopathological features. Person-

ality and Individual Differences, 27, 1285–1295.

Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression

diagnostic and severity measure. Psychiatric Annals, 32,

509–521.

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). Validity of a

brief depression severity measure. Journal of General Internal

Medicine, 16, 606–613.

Lee, P. W., Schulberg, H. C., Raue, P. J., & Kroenke, K. (2007).

Concordance between the PHQ-9 and the HSCL-20 in depressed

primary care patients. Journal of Affective Disorders, 99,

139–145.

Lorenzo-Seva, U., & Ferrando, P. J. (2013). FACTOR 9.2: A

comprehensive program for fitting exploratory and semiconfir-

matory factor analysis and IRT models. Applied Psychological

Measurement, 37, 497–498.

Lowe, B., Decker, O., Muller, S., Brahler, E., Schellberg, D., Herzog,

W., et al. (2008). Validation and standardisation of the Gener-

alised Anxiety Disorder Screener (GAD-7) in the general

population. Medical Care, 46, 266–274.

Mansell, W. (2005). Control theory and psychopathology: An

integrative approach. Psychology and Psychotherapy: Theory,

Research and Practice, 78, 141–178.

Mansell, W., Carey, T. A., & Tai, S. (2012). A Transdiagnostic approach

to CBT using method of levels therapy. East Sussex: Routledge.

Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2008). Cognitive

behavioural processes across psychological disorders: A review of

the utility and validity of the transdiagnostic approach. Interna-

tional Journal of Cognitive Therapy, 1, 181–191.

Mansell, W., Harvey, A., Watkins, E., & Shafran, R. (2009). Conceptual

foundations of the transdiagnostic approach to CBT. Journal of

Cognitive Psychotherapy: An International Quarterly, 23, 13–26.

McEvoy, P. M., & Mahoney, A. E. (2012). To be sure, to be sure:

Intolerance of uncertainty mediates symptoms of various anxiety

disorders and depression. Behavior Therapy, 43(3), 533–545.

McHugh, R. K., Murray, H. W., & Barlow, D. H. (2009). Balancing

fidelity and adaptation in the dissemination of empirically-

supported treatments: The promise of transdiagnostic interven-

tions. Behaviour Research and Therapy, 47, 946–953.

McManus, F., Shafran, R. L., & Cooper, Z. (2010). What does a

transdiagnostic approach have to offer the treatment of anxiety

disorders? British Journal of Clinical Psychology, 49, 491–505.

Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990).

Development and validation of the penn state worry question-

naire. Behaviour Research and Therapy, 28, 487–495.

Molina, S., & Borkovec, T. D. (1994). The penn state worry question-

naire: Psychometric properties and associated characteristics. In G.

C. L. Davey & F. Tallis (Eds.), Worrying: Perspectives on theory,

assessment and treatment (pp. 265–283). Chichester: Wiley.

Muris, P., Merckelbach, H., & Horselenberg, R. (1996). Individual

differences in thought suppression. The white bear suppression

inventory: Factor structure, reliability, validity and correlates.


Powers, W. T. (1973). Behavior: The control of perception. Chicago:

Aldine Publishing Co.

Snider, J. G., & Osgood, C. E. (1969). Semantic differential

technique: A sourcebook. Chicago: Aldine.

Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lowe, B. (2006). A

brief measure for assessing generalised anxiety disorder: The

GAD-7. Archives of Internal Medicine, 166, 1092–1097.

Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate

statistics (5th ed.). Boston: Allyn and Bacon.

Timmerman, M. E., & Lorenzo-Seva, U. (2011). Dimensionality

assessment of ordered polytomous items with parallel analysis.

Psychological Methods, 16, 209–220.

Veale, D., Ellison, N., Boschen, M., Costa, A., Whelan, C., Muccio,

F., et al. (2013). Development of an inventory to measure

specific phobia of vomiting (emetophobia). Cognitive Therapy

and Research, 37, 595–604.

Veale, D., Eshkevari, E., Kanakam, N., Ellison, N., Costa, A., &

Werner, T. (2014). The Appearance Anxiety Inventory: Valida-

tion of a process measure in the treatment of body dysmorphic

disorder. Behavioural and Cognitive Psychotherapy, 42, 605–616.

Wegner, D. M., & Zanakos, S. (1994). Chronic thought suppression.

Journal of Personality, 62, 615–640.

Wells, A. (2009). Metacognitive therapy for anxiety and depression.

New York: Guildford Press.

Wells, A., & Matthews, G. (1994). Attention and emotion: A clinical

perspective. Hove: Lawrence Erlbaum.

Wells, A., & Papageorgiou, C. (1998). Relationships between worry,

obsessive-compulsive symptoms and meta-cognitive beliefs.


Wilson, P., & Cooper, C. (2008). Finding the magic number. The

Psychologist, 21, 866–867.

Zwick, W. R., & Velicer, W. F. (1986). Comparison of five rules for

determining the number of components to retain. Psychological

Bulletin, 99, 432–442.

Cogn Ther Res

123


Professor David Veale, Consultant Psychiatrist, The Priory … · transdiagnostic’ in that they were elevated in all disorders tested and in at least four different disorders. A

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